Provider Demographics
NPI:1508812579
Name:HASAN, SHAHZAD (MD)
Entity Type:Individual
Prefix:
First Name:SHAHZAD
Middle Name:
Last Name:HASAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776874
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6874
Mailing Address - Country:US
Mailing Address - Phone:314-291-7997
Mailing Address - Fax:314-739-1471
Practice Address - Street 1:12774 BOENKER LN
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2436
Practice Address - Country:US
Practice Address - Phone:314-291-7997
Practice Address - Fax:314-739-1471
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000151353207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H35450OtherUPIN
H35450OtherUPIN
MO205360704Medicare ID - Type UnspecifiedMISSOURI MEDICAID